Yonsei Med J.  2017 Jul;58(4):793-799. 10.3349/ymj.2017.58.4.793.

Administration of a High-Dose Erythropoietin-Stimulating Agent in Hemodialysis Patients is Associated with Late Arteriovenous Fistula Failure

• Jeong HY
• Ko EJ
• Kim SH
• Lee MJ
• Cho HJ
• Yang DH
• Lee SY

• KMID: 2419086
• DOI: http://doi.org/10.3349/ymj.2017.58.4.793

Abstract

PURPOSE
Investigating the risk of vascular access failure is critical for maintenance hemodialysis (MHD) patients. Erythropoietin stimulating agents (ESA) typically used for anemia of chronic kidney disease (CKD) may also stimulate neointimal hyperplasia, which is the most important factor in late arteriovenous fistula (AVF) failure. The aim of this study was to investigate whether ESA treatment is associated with late AVF failure.
MATERIALS AND METHODS
The late AVF failure group comprised 51 patients who underwent percutaneous intervention or surgery for fistula revision after successful use for at least three months. There were 51 controls whose AVF had been patent for at least 24 months.
RESULTS
The mean time from the first cannulation to late loss of AVF patency was 8.4±4.2 months. The average weekly dose of ESA was significantly higher in patients with AVF failure (4782.2±2360.5 IU/mL/wk vs. 7161.8±2775.2 IU/mL/wk, p<0.001). The only independent predictor of late AVF failure in multivariate analysis was high average ESA dose (odds ratio=1.015, 95% confidence interval=1.002-1.028, p=0.022).
CONCLUSION
Patients with late AVF patency loss exhibit an association with a higher dose of ESA, although causality is unproven. Further study to elucidate potential mechanisms is warranted.

Keyword

Arteriovenous fistula; chronic kidney disease; erythropoietin stimulating agents; maintenance hemodialysis; neointimal hyperplasia

MeSH Terms

Arteriovenous Fistula/*etiology
Dose-Response Relationship, Drug
Erythropoietin/*administration & dosage/*adverse effects
Female
Hemoglobins/metabolism
Humans
Logistic Models
Male
Middle Aged
Multivariate Analysis
*Renal Dialysis
Hemoglobins
Erythropoietin

Figure

• 

  Fig. 1 Flow chart illustrating study population enrollment. A total of 1625 patients received MHD at the hemodialysis center of CHA Bundang Medical Center between 2006 and 2015. Vascular access failure events occurred in 245 patients. After applying exclusion criteria, only 51 patients were eligible for the late AVF failure group. AVG, arteriovenous graft; AVF, arteriovenous fistula; MHD, maintenance hemodialysis.

• 

  Fig. 2 Mean ESA dose according to AVF patency loss. The mean ESA dose was 7161.8±2775.2 IU/mL/wk for the AVF failure group and 4782.2±2360.5 IU/mL/wk for the control group. The difference in mean ESA dose between the two groups was statistically significant (*p<0.001). AVF, arteriovenous fistula; ESA, erythropoietin stimulating agent.

• 

  Fig. 3 Mean hemoglobin level according to AVF patency loss. The mean hemoglobin level was 9.6±0.5 g/dL in the AVF failure group and 9.5±1.5 g/dL in the control group. The mean hemoglobin level was slightly higher in the AVF failure group, but the difference was not statistically significant (p=0.728). AVF, arteriovenous fistula.

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